Chiến lược tái thông mạch vành trong hội chứng vành cấp

14th Vietnam National Congress of Cardiology
Da Nang, Vietnam
October 11-14, 2014

Acute Coronary Syndromes
Reperfusion Strategies

Gregory W. Barsness, MD, FACC, FAHA, FSCAI
Director, Mayo Clinic Cardiac Intensive Care Unit
Director, Mayo Clinic EECP Laboratory
©2013 MFMER | slide-1


Disclosures

No pertinent financial conflicts
Off-label Usage:
DES in ACS

©2013 MFMER | slide-2


ACS Epidemiology
Proportion of STEMI vs NSTE-ACS
> 5 million ED visits for chest pain
1.57 million admissions for ACS
(1 MI every 44 seconds in US)
~ 70% of all acute MI are NSTEMI
100

NSTEMI

STEMI

Percent

80
60
40
20
0
1999

2000

2001

2002

2003

2004

2005

Year
Chan, et al. Circ 2009;119
2013 AHA Heart and Stroke Statistics, cardiosource.org

©2013 MFMER | slide-3

All-Cause Mortality in STEMI vs NSTEMI
4606 AMI Pts Undergoing Angiography
70

Mortality (%)

60

NSTEMI

50
40
30

STEMI

20
10
0
0

1

2

3

4
Years

5

6

7

8

Chan, et al. Circ 2009;119
©2013 MFMER | slide-4


Therapy in NSTE-ACS is Complex
Anticoagulants: UFH LMWH Fondaparinux Bivalirudin
Antiplatelets:

ASA Clopidogrel Prasugrel
(dose)
(dose)

Ticagrelor

IV antiplatelets: None Abciximab Eptifibatide/Tirofiban

Cath strategy:

Early

Delayed

Never

144 Different Combinations with
different effects on bleeding and
thrombosis risk!
©2013 MFMER | slide-5


Guideline Adherence and Outcome
In-hosp mortality (%)

7
6

5.95

5.16

5
4
3

Adjusted
Unadjusted

6.33

5.07

4.97

4.63

4.16

4.17

Every 10%  in guidelines adherence

2

11%  in mortality

1

0
<=25%

25-50%

50-75%

>=75%

Hospital composite quality quartiles

Peterson, et al. ACC 2004
©2013 MFMER | slide-6

Early-Invasive vs Delayed-Invasive
(Ischemia-Guided) Strategy
ISAR-COOL
ICTUS
VANQWISH

(1998)

(2005)

MATE
TIMI III-B

RITA-3

(2002)

TRUCS
(1994)

VINO

TACTICS25% Relative Mortality Risk Reduction
TIMI 18
Over 2 Years!
FRISC II

(2001)
(1999)

Weight of
the evidence
Favors “Conservative”
n=920

No difference
n=2,874

Favors Early Invasive
n=7,018
©2013 MFMER | slide-7


Timing of Intervention in ACS (TIMACS)
Early (<24hr) vs Delayed (>36)
Kaplan-Meier Cumulative Risk of the Death, MI or Stroke
Stratified by Baseline GRACE Risk Score: Low (≤140) vs High Risk (>140)
0.25
Delayed
Cumulative Hazard

High Risk
Early

Early
Delayed

Low-toIntermendiate
Risk

0.00
0
Early intervention (med 14 hrs)

90
Days

180
Delayed intervention (med 50 hrs)

Mehta SR et al. NEJM 2009;360:2165-2175
©2013 MFMER | slide-11


Timing of Intervention in ACS (TIMACS)
Early (<24hr) vs Delayed (>36)
Kaplan-Meier Cumulative Risk of the Death, MI or Stroke
Stratified by Baseline GRACE Risk Score: Low (≤140) vs High Risk (>140)
0.25
Delayed
Cumulative Hazard

High Risk
Early

I IIa IIb III

0.00
0
Early intervention (med 14 hrs)

90
Days

180
Delayed intervention (med 50 hrs)

Mehta SR et al. NEJM 2009;360:2165-2175
©2013 MFMER | slide-12


ABOARD
Immediate vs Delay Angio in High-Risk ACS
Peak Troponin I *
30-Day MACE
30-Day Major Bleeding

16
13.7

14
12

10.2

10
8

6.8

6
4
2

4
2.1

1.7

0
Immediate (Mean 70 Min)
*Primary Endpoint
n=352
All p=NS

Delayed (Mean 21 Hrs)

Montalescot, et al. JAMA 2009;302:947
©2013 MFMER | slide-13


Non ST Elevation ACS
Management Strategies
Definite/Possible ACS
Initiate Aspirin, Beta-blockers (PO), Nitrates, Anticoagulants, Telemetry

Early Invasive Strategy
•Electrical or hemodynamic instability
•Refractory, resistant, recurrent angina
•Elevated Risk Score (GRACE>140, TIMI>2)

•Abnormal biomarkers (20% change)
•New ST segment depression
•PCI in past 6 months or prior CABG
•DM or CKD (Stage II or III)
•EF <40%
•Mod Risk Score (GRACE 109-140,TIMI ≥ 2)

Coronary angiography
Within 2 Hours
ACC/AHA Guidelines UA/NSTEMI 2014
©2013 MFMER | slide-14


Non ST Elevation ACS
Management Strategies
Definite/Possible ACS
Initiate Aspirin, Beta-blockers (PO), Nitrates, Anticoagulants, Telemetry

Early Invasive Strategy
•Electrical or hemodynamic instability
•Refractory, resistant, recurrent angina
•Elevated Risk Score (GRACE>140, TIMI>2)
•Abnormal biomarkers (20% change)
•New ST segment depression
•PCI in past 6 months or prior CABG
•DM or CKD (Stage II or III)
•EF <40%
•Mod Risk Score (GRACE 109-140,TIMI ≥ 2)

Coronary angiography

Within 24 hours
ACC/AHA Guidelines UA/NSTEMI 2014
©2013 MFMER | slide-15


Non ST Elevation ACS
Management Strategies
Definite/Possible ACS
Initiate Aspirin, Beta-blockers (PO), Nitrates, Anticoagulants, Telemetry

Early Invasive Strategy
•Electrical or hemodynamic instability
•Refractory, resistant, recurrent angina
•Elevated Risk Score (GRACE>140, TIMI>2)
•Abnormal biomarkers (20% change)
•New ST segment depression
•PCI in past 6 months or prior CABG
•DM or CKD (Stage II or III)
•EF <40%
•Mod Risk Score (GRACE 109-140,TIMI ≥ 2)

Coronary angiography
25-72 Hours
ACC/AHA Guidelines UA/NSTEMI 2014
©2013 MFMER | slide-16


Non ST Elevation ACS
Management Strategies
Definite/Possible ACS

Initiate Aspirin, Beta-blockers (PO), Nitrates, Anticoagulants, Telemetry

Early Invasive Strategy
•Electrical or hemodynamic instability
•Refractory, resistant, recurrent angina
•Elevated Risk Score (GRACE>140, TIMI>2)
•Abnormal biomarkers (20% change)
•New ST segment depression
•PCI in past 6 months or prior CABG
•DM or CKD (Stage II or III)
•EF <40%
•Mod Risk Score (GRACE 109-140,TIMI ≥ 2)

Coronary angiography

Ischemia-Guided Strategy
• TIMI Risk Score ≤2 (Especially Tn- Women!)
• No ST segment deviation
• Negative biomarkers

Recurrent Symptoms
Heart failure
Serious Arrhythmia
Worsening MR

EF<40%

+

Stable

Assessment of EF
Stress Test

ACC/AHA Guidelines UA/NSTEMI 2014
©2013 MFMER | slide-17


Non ST Elevation ACS
Management Strategies
Definite/Possible ACS
Initiate Aspirin, Beta-blockers (PO), Nitrates, Anticoagulants, Telemetry

Early Invasive Strategy
•Electrical or hemodynamic instability
•Refractory, resistant, recurrent angina
•Elevated Risk Score (GRACE>140, TIMI>2)
•Abnormal biomarkers (20% change)
•New ST segment depression
•PCI in past 6 months or prior CABG
•DM or CKD (Stage II or III)
•EF <40%
•Mod Risk Score (GRACE 109-140,TIMI ≥ 2)

Coronary angiography
12-48 Hours

Ischemia-Guided Strategy
• TIMI Risk Score ≤2 (Especially Tn- Women!)
• No ST segment deviation

• Negative biomarkers

Recurrent Symptoms
Heart failure
Serious Arrhythmia
Worsening MR

EF<40%

+

Stable

Assessment of EF
Stress Test

ACC/AHA Guidelines UA/NSTEMI 2014
©2013 MFMER | slide-18


STEMI Management Algorithm

Www.

www.cardiosource.org
©2013 MFMER | slide-20


35-Day Mortality Reduction with Thrombolysis
58,600 Patients – 9 Trials

30

Mortality (%)

P<0.00001
18%
reduction
20

Thrombosis
23.6

Placebo

18.7
16.9
15.2
13.4

13.2
11.5

10

13.8

10.6

9.6

7.5

8.4

0

Total

BBB

Ant MI

Inf MI

Other ST
-

ST ¯

FTT: Lancet, 1994
©2013 MFMER | slide-21


Primary PCI vs. Fibrinolysis
Meta-analysis of 23 RCTs of 7739 pts
NNT = 50

NNT = 17

4-6 week outcomes

25

21

PCI

20

Lysis

15
%

10

13
7

9

5

7

7

6

2.2

1

2

0
Death

Re-MI

Rec
Isch

Total
stroke

0

8
5

1

Hem
stroke

Major
bleed

Death

MI
Stroke

Keeley and Grines. Lancet 2003.
©2013 MFMER | slide-22


Early PCI after Lysis

“Pharmaco-Invasive” Strategy
Ischemic Endpoint, %

30
Routine PCI

24.4

Selective PCI

21.2

20
11.6

20.3

No excess in major bleeding
17.1
with routine PCI
10.7

10

10

11

9.3

4.4
0
CAPITAL-AMI

1.6

CARESS-inAMI

NORDISTEMI

TRANSFER
AMI

2.3
<3.0
3.9
Fibrinolysis to routine PCI (h)

GRACIA I

16.7

Adapted from Verheugt, NEJM 2009
©2013 MFMER | slide-23


Non-PCI Hospital Triage and Transfer
Symptom Onset
Symptoms
<2-4 hours
Low

Bleeding risk

Fibrinolytic with
Antithrombin + clopidogrel

Symptoms
>2-4 hours
High
Transfer for
PPCI

Transfer for PCI 3-16 hours
©2013 MFMER | slide-24


Minnesota
0

100

200

Wisconsin

Minneapolis/
St. Paul

Rochester

Iowa
©2013 MFMER | slide-25


Mayo NSTE-ACS Protocol

Tools:
ECG within 10 min, repeat q 15-30 min
Biomarkers (Troponin), repeat 3-6 hrs
Risk scores (TIMI, Grace)

©2013 MFMER | slide-26


Mayo NSTE-ACS Protocol

©2013 MFMER | slide-27


Mayo NSTE-ACS Protocol

©2013 MFMER | slide-28


©2013 MFMER | slide-29